JOB DESCRIPTION

Job Summary

Molina Healthcare Services (HCS) Department works with members, providers, and multidisciplinary team members to assess, facilitate, plan, and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service. The Lead, HCS (Clinical) functions as clinical staff lead in the health plan HCS Department. Responsibilities include oversight capabilities of daily administrative functions including staffing schedules, productivity, and work quality.

 

KNOWLEDGE/SKILLS/ABILITIES

Assists in training of all staff according to Department standards, policies, and procedures. Evaluates the work performance of the health plan HCS Department staff. Consults with the Management of HCS to devise and implement corrective action as necessary to improve staff performance. Acts as a supportive resource to the HCS Department staff, assist in devising/implementing strategies of assignment delegation, facilitating HCS processes and communicating/coordinating activities. Resolves problems and complaints that may arise in day-to-day operations that involve clinical HCS staff. Communicates findings to the Supervisor or Manager, HCS Department for resolution. Maintains a minimal caseload as determined by leadership to ensure communication and adherence to appropriate guidelines and support staff who have an ongoing member case load for regular outreach and management. As a Lead RN provide support, recommendations, and education as appropriate to all other clinical and non-clinical staff. Collaborates with and keeps HCS Management apprised of operational issues, staffing issues, system, and program needs. Monitors the HCS Department staff workload for adherence to the Policies, Procedures, Guidelines, Medicare Model of Care, and deadlines. Assures oversight and direction of individuals primarily responsible and assures timely completion. Actively participates in the Department auditing program to review and communicate findings with staff and identify opportunities for improved quality and compliance. Acts as liaison to both internal and external customers on behalf of both Molina and the HCS Department areas. Maintains confidentiality, cooperative and effective workplace relationships and adheres to company Code of Conduct. Attends/participates in departmental, company-wide, and external committees, task forces, or work groups, as assigned. As an opportunity to encourage staff, share monthly quality and productivity scores with individual staff for awareness. Incumbents in this role must complete courses required to obtain licensure in all states. Utilization Review Lead responsibilities also include but not limited to, collaborate with UM Leadership to ensure the Daily Auth Reconciliation Report (DARR) is run every workday and cases found non-compliant or missing compliance elements are remediated promptly Case Management (CM) Lead responsibilities also include but not limited to, collaborate with CM Leadership ensuring the Care Management Monitoring Tool (CMMT) is run every workday and cases are addressed to maintain Health Risk Assessment (HRA) and Care Plan compliance.

 

JOB QUALIFICATIONS

Required Education

Completion of an accredited Licensed Registered Nurse (RN), Licensed Vocational Nurse (LVN), or Licensed Practical Nurse (LPN) Program OR Bachelor's or Master's Degree in a health or social science, psychology, gerontology, public health or social work.

Required Experience

3+ years of hospital or medical clinic experience.

Required License, Certification, Association

If licensed, license must be active, unrestricted and in good standing.

Preferred Education

Graduate from an Accredited School of Nursing. Bachelor's Degree in Nursing preferred.

Preferred Experience

3-5 years clinical practice with managed care, hospital nursing, utilization and/or care management experience.

Preferred License, Certification, Association

Active, unrestricted State Registered Nursing (RN) license in good standing.

 

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.